Suture - wikidoc Suture Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] A suture is a medical device that doctors , and especially surgeons , use to hold skin , internal organs , blood vessels and all other tissues of the human body together, after they have been severed by injury or surgery . They must be strong (so they do not break), non-toxic and hypoallergenic (to avoid adverse reactions in the body), and flexible (so they can be tied and knotted easily). In addition, they must lack the so called "wick effect", which means that sutures must not allow fluids to penetrate the body through them from outside, which could easily cause infections. Absorbable and nonabsorbable sutures Sutures are divided into two kinds - those which are absorbable and will break down harmlessly in the body over time without intervention, and those which are non-absorbable and must be manually removed if they are not left indefinitely. The type of suture used varies on the operation, with the major criteria being the demands of the location and environment. Sutures to be placed internally would require re-opening if they were to be removed.

Sutures which lie on the exterior of the body can be removed within minutes, and without re-opening the wound. As a result, absorbable sutures are often used internally; non-absorbable externally. Sutures to be placed in a stressful environment, for example the heart (constant pressure and movement) or the bladder (adverse chemical presence) may require specialized or stronger materials to perform their role; usually such sutures are either specially treated, or made of special materials, and are often non-absorbable to reduce the risk of degradation. Absorbable sutures Absorbable sutures are made of materials which are broken down in tissue after a given period of time, which depending on the material can be from ten days to eight weeks. They are used therefore in many of the internal tissues of the body. In most cases, three weeks is sufficient for the wound to close firmly. The suture is not needed any more, and the fact that it disappears is an advantage, as there is no foreign material left inside the body and no need for the patient to have the sutures removed. Absorbable sutures were originally made of the intestines of sheep, the so called catgut .

The manufacturing process was similar to that of natural musical strings for violins and guitar , and also of natural strings for tennis racquets. The inventor, a 10th century surgeon named al-Zahrawi reportedly discovered the dissolving nature of catgut when his lute 's strings were eaten by a monkey. Today, gut sutures are made of specially prepared beef and sheep intestine, and may be untreated (plain gut), tanned with chromium salts to increase their persistence in the body (chromic gut), or heat-treated to give more rapid absorption (fast gut). However, the major part of the absorbable sutures used are now made of synthetic polymer fibers, which may be braided or monofilament; these offer numerous advantages over gut sutures, notably ease of handling, low cost, low tissue reaction, consistent performance and guaranteed non-toxicity. In Europe and Japan, gut sutures have been banned due to concerns over bovine spongiform encephalopathy (mad-cow disease), although the herds from which gut is harvested are certified BSE-free.

Each major suture manufacturer has its own proprietary formulations for its brands of synthetic absorbable sutures; various blends of polyglycolic acid (Biovek for example), lactic acid or caprolactone are common. Occasionally, absorbable sutures can cause inflammation and be rejected by the body rather than absorbed. Non-absorbable sutures 8 nonabsorbable sutures in a person's left thumb. Nonabsorbable sutures are made of materials which are not metabolized by the body, and are used therefore either on skin wound closure, where the sutures can be removed after a few weeks, or in some inner tissues in which absorbable sutures are not adequate. This is the case, for example, in the heart and in blood vessels, whose rhythmic movement requires a suture which stays longer than three weeks, to give the wound enough time to close. Other organs, like the bladder, contain fluids which make absorbable sutures disappear in only a few days, too early for the wound to heal.

Inflammation caused by the foreign protein in some absorbable sutures can amplify scarring, so if other types of suture are less antigenic (ie, do not provoke as much of an immune response ) it would represent a way to reduce scarring. There are several materials used for nonabsorbable sutures. The most common is a natural fiber, silk , which undergoes a special manufacturing process to make it adequate for its use in surgery. Other nonabsorbable sutures are made of artificial fibers, like polypropylene , polyester or nylon ; these may or may not have coatings to enhance their performance characteristics. Finally, stainless steel wires are commonly used in orthopedic surgery and for sternal closure in cardiac surgery . Three sutures to a person's right arm, near the elbow. Surgical needles for use with sutures Traumatic needles are needles with holes or eyes which are supplied to the hospital separate from their suture thread. The suture must be threaded on site, as is done when sewing at home. Atraumatic needles with sutures comprise an eyeless needle attached to a specific length of suture thread. The suture manufacturer swages the suture thread to the eyeless atraumatic needle at the factory.

There are several advantages to having the needle pre-mounted on the suture. The doctor or the nurse or odp does not have to spend time threading the suture on the needle. More important, the suture end of a swaged needle is smaller than the needle body. In traumatic needles with eyes, the thread comes out of the needle's hole on both sides. When passing through the tissues, this type of suture rips the tissue to a certain extent, thus the name traumatic. Nearly all modern sutures feature swaged atraumatic needles.

There are several shapes of surgical needles, including: straight Needles may also be classified by their point geometry; examples include: taper (needle body is round and tapers smoothly to a point) cutting (needle body is triangular and has a sharpened cutting edge on the inside) reverse cutting (cutting edge on the outside) trocar point or tapercut (needle body is round and tapered, but ends in a small triangular cutting point) blunt points for sewing friable tissues side cutting or spatula points (flat on top and bottom with a cutting edge along the front to one side) for eye surgery Finally, atraumatic needles may be permanently swaged to the suture or may be designed to come off the suture with a sharp straight tug. These "pop-offs" are commonly used for interrupted sutures, where each suture is only passed once and then tied. Sizes of sutures Suture sizes are defined by the United States Pharmacopeia (U.S.P.). Sutures were originally manufactured ranging in size from #1 to #6, with #1 being the smallest. A #4 suture would be roughly the diameter of a tennis racquet string.

The manufacturing techniques, derived at the beginning from the production of musical strings, did not allow thinner diameters. As the procedures improved, #0 was added to the suture diameters, and later, thinner and thinner threads were manufactured, which were identified as #00 (#2-0 or #2/0) to #000000 (#6-0 or #6/0). Modern sutures range from #5 (heavy braided suture for orthopedics) to #11-0 (fine monofilament suture for ophthalmics). Atraumatic needles are manufactured in all shapes for most sizes. The actual diameter of thread for a given U.S.P. size differs depending on the suture material class. A wound before and after being closed by simple interrupted sutures U.S.P. Subcuticular Removal of sutures Whilst some sutures are intended to be permanent, and others in specialized cases may be kept in place for an extended period of many weeks, as a rule sutures are a short term device to allow healing of a trauma or wound. According to about.com 's article on nursing: [1] "Different parts of the body heal at different intervals.

Common time to remove stitches will vary: facial wounds 3-5 days; scalp wound 7-10 days; limbs 10-14 days; joints 14 days; trunk of the body 7-10 days. "Not all stitches must be removed. If a small area remains unhealed, notify the health care practitioner. Then if ordered, remove sutures from the healed area only." Suture materials Advantages Very high knot-pull tensile strength , good knot security due to special excellent handling features Very high knot-pull tensile strength, good knot security due to special surface finish, improved smoothness due to the dry presentation of the thread, excellent handling features High initial tensile strength, guaranteed holding power through the critical wound healing period. Smooth passage through tissue, easy handling, excellent knotting ability, secure knot tying Tensile strength retention, guaranteed holding power Indications For all surgical procedures especially when tissues that regenerate faster are involved. General closure, ophthalmic, orthopedics, obstetrics/gynecology and gastro-intestinal tract surgery. For all surgical procedures, especially for tissues that regenerate faster.

Subcutaneous , intracutaneous closures, abdominal and thoracic surgeries PDS is particularly useful where the combination of an absorbable suture and extended wound support is desirable, pediatric cardiovascular surgery, ophthalmic surgery Contraindications Not recommended for incisions that require the sustaining of the tissues for a prolonged period of time. Not recommended for an incision that requires sustaining of the tissues for a prolonged period of time. This suture being absorbable should not be used where extended approximation of tissue is required. This type of suture being absorbable is not to be used where prolonged approximation of tissues under stress is required and/ or in conjunction with prosthetic devices Precautions Special precautions should be taken in patients with cancer , anemia and malnutrition conditions. They tend to absorb the sutures at a higher rate. Cardiovascular surgery , due to the continued heart contractions. It is absorbed much faster when used in the mouth and in the vagina , due to the presence of microorganisms . Avoid using where long term tissue approximation is needed. Absorption is faster in infected tissues It is absorbed much faster when used in the mouth and in the vagina, due to the presence of microorganism.

Cardiovascular surgery, due to the continued heart contractions. Special precautions should be taken in patients with cancer, anemia and malnutrition conditions. They tend to absorb this suture at a higher rate. Special precautions should be taken in elderly patients and patients with history of anemia and malnutrition conditions. As with any suture material, adequate knot security requires the accepted surgical technique of flat and square ties. The PDS suture knots must be properly placed to be secure. Conjunctival and vaginal mucosal sutures remaining in placed for extended periods may be associated with localized irritation. Subcuticular sutures should be placed as deeply as possible in order to minimize the erythema and induration normally associated with absorption. U.S.P. Needle Pull Specifications Other facts Tissue adhesives In recent years, topical cyanoacrylate adhesives ("liquid stitches") have been used in combination with, or as an alternative to, sutures in wound closure. The adhesive remains liquid until exposed to water or water-containing substances/tissue, after which it cures ( polymerizes ) and forms a flexible film that bonds to the underlying surface.

The tissue adhesive has been shown to act as a barrier to microbial penetration as long as the adhesive film remains intact. Limitations of tissue adhesives include contraindications to use near the eyes and a mild learning curve on correct usage. Antimicrobial sutures Another recent development in wound closure involves the use of sutures coated with antimicrobial substances to reduce the chances of wound infection . While long-term studies are not yet available, preliminary results indicate that these sutures are effective at keeping bacteria out of wounds. See also Suture materials comparison chart Advertising Suture materials comparison chart Numerous different surgical suture materials exist. [1] The following table compares some of the most common absorbable sutures. Plain catgut Polydioxanone (PDS) Description Absorbable biological suture material. Plain is an absorbable suture made by twisting together strands of purified collagen taken from bovine intestines . The natural plain thread is precision ground in order to achieve a monofilament character and treated with a glycerol containing solution. Plain is absorbed by enzymatic degradation. Absorbable biological suture material. Chromic is an absorbable suture made by twisting together strands of purified collagen taken from bovine intestines.

Due to undergoing a ribbon stage chromicisation (treatment with chromic acid salts), the chromic offers roughly twice the stitch-holding time of plain catgut. The natural chromic thread is precision ground in order to achieve a monofilament character and treated with a glycerol containing solution. Chromic is absorbed by enzymatic degradation. Note – catgut is no longer used in the UK for human surgery. It is a synthetic absorbable suture material. Braided synthetic absorbable multifilament made of polyglycolic acid and coated with N- laurin and L- lysine , which render the thread extremely smooth, soft and knot safe. It is a synthetic absorbable suture material. Monofilament synthetic absorbable suture, prepared from the polyester, poly (p-dioxanone). Composition Strength retention for at least 7 days. Maintains strength for 10–14 days [2] 84% at 2 weeks, 23% at 4 weeks [2] 80% at 2 weeks, 44% at 8 weeks.

Complete absorption within 200 days [2] Structure Synthetic through the critical wound Treatment Type of absorption Proteolytic enzymatic digestion complete by 90 days. Proteolytic enzymatic digestion complete in 70 days. Absorption by enzymatic digestion and starts losing tensile strength on implantation from 18–21 days of catgut chromic Absorption by hydrolysis complete between 60 and 90 days. Always predictable and reliable Wound support can remain up to 42 days, however tensile strength decreases to about 70% at 14 days and 25% at 42 days Tissue reaction Moderate. Plain catgut enjoys lower tissue reaction as compared to chromicised. Moderate. USP 6-0 (1 metric) to USP 5 (100 metric). USP 6-0 (1 metric) to USP 5 (100 metric).

USP 6-0 (1 metric) to USP 2 (5 metric) USP 6-0 (1 metric) to USP 2 (5 metric) Sterilization Sterilizing fluid containing EO [3] Sterilizing fluid containing EO [3] Advantages Very high knot-pull tensile strength, good knot security due to special excellent handling features Very high knot-pull tensile strength, good knot security due to special surface finish, improved smoothness due to the dry presentation of the thread, excellent handling features High initial tensile strength, guaranteed holding power through the critical wound healing period. Smooth passage through tissue, easy handling, excellent knotting ability, secure knot tying Tensile strength retention, guaranteed holding power Indications For all surgical procedures especially when tissues that regenerate faster are involved. General closure, ophthalmic, orthopedics, obstetrics/gynecology and gastro-intestinal tract surgery. For all surgical procedures, especially for tissues that regenerate faster.

Subcutaneous , intracutaneous closures, abdominal and thoracic surgeries PDS is particularly useful where the combination of an absorbable suture and extended wound support is desirable, pediatric cardiovascular surgery, ophthalmic surgery Contraindications Not recommended for incisions that require the sustaining of the tissues for a prolonged period of time. Not recommended for an incision that requires sustaining of the tissues for a prolonged period of time. This suture being absorbable should not be used where extended approximation of tissue is required. This type of suture being absorbable is not to be used where prolonged approximation of tissues under stress is required and/ or in conjunction with prosthetic devices Precautions Special precautions should be taken in patients with cancer, anemia and malnutrition conditions. They tend to absorb the sutures at a higher rate. Cardiovascular surgery , due to the continued heart contractions. It is absorbed much faster when used in the mouth and in the vagina , due to the presence of microorganisms . Avoid using where long term tissue approximation is needed. Absorption is faster in infected tissues It is absorbed much faster when used in the mouth and in the vagina, due to the presence of microorganism.

Cardiovascular surgery, due to the continued heart contractions. Special precautions should be taken in patients with cancer, anemia and malnutrition conditions. They tend to absorb this suture at a higher rate. Special precautions should be taken in elderly patients and patients with history of anemia and malnutrition conditions. As with any suture material, adequate knot security requires the accepted surgical technique of flat and square ties. The PDS suture knots must be properly placed to be secure. Conjunctival and vaginal mucosal sutures remaining in place for extended periods may be associated with localized irritation. Subcuticular sutures should be placed as deeply as possible in order to minimize the erythema and induration normally associated with absorption. References Acufirm - Suture Materials Suture Materials Catgut chromic PGA (glycolic acid) is a braided and coated, synthetic, absorbable suture material made from the polymer of glycolic acid. PGA diminishes by simple hydrolysis within 60 - 90 days and causes only the minimum of tissue reaction. Typical qualities of PGA are the high initial tensile strength, the litheness during the use as well as the excellent stitching characteristics.

PGA - suture material is marked violet Color: the polymer of glycolic acid Coating: by simple hydrolysis within 60 - 90 days PGA-rapid - by simple hydrolysis within 40 - 45 days Characteristic: dermal and hypodermic stitching, plastic surgery, ophthalmology, dental, gastroenterology, fascia, vasculature, gynecology, urology Tensile strength: Approx. 60% after two weeks, 1% after five weeks PGA-rapid approx. 50% after 7 days < 1% after 10 to 15 days Stitching characteristics: one, two, three or a dozen in environmentally friendly cardboard box Durability: USP: 10/0 to 2 - metric: 0,2 to 5 Length of thread: from 30 cm to 150 cm PDO (Polydioxanone) is a monofilament, synthetic, absorbable suture material from the polymer of polydioxanone. The resorption time is approx. 150 - 180 days.

PDO has also excellent stitching characteristics and after 5 weeks it has still about 50% of its original tear strength. PDO – suture material is marked red Color: Through hydrolysis within 150-180 days Characteristic: Long lasting tensile strength and longer resorption time than PGA Recommendation of use: For skin suture with slow healing, plastic surgery, gastroenterology, gynecology, urology, orthopedics Tensile strength: Approx. 50% of its original strength after five weeks Attaching characteristics: one, two, three or a dozen in environmentally friendly cardboard box Durability: USP: 6/0 bis 1 - metric: 0,7 bis 4 Length of thread: from 30 cm to 150 cm Polypropylene Is a non absorbable monofilament suture material with an even surface free of pore which guarantees clean and easy stitching by good gliding characteristics. Because polypropylene does not break up hydrolytically, it is suitable for sunk and lasting suture.

Polypropylene – suture material is marked dark-blue Color: blue, USP 10/0 and 9/0 blue/black Made from: Flat and nonporous surface, not hydrolytically absorbable, durable fixture through this Recommendation of use: For sunk and lasting sutures as its widely inert, Cardiosurgery, plastic surgery Tensile strength: one, two, three or a dozen in environmentally friendly cardboard box Durability: USP: 11/0 bis 2 - metric: 0,1 bis 5 Length of thread: from 10 to 150 cm PVDF (Polyvinylidenfluorid) is a monofilament, non-absorbable suture material. The outstanding qualities are a very high resistance to tearing and an excellent knot fit. PVDF is biologically and chemically absolutely inert and is more resistant than polypropylene.

PVDF Suture material is marked light grey Color: USP 8/0 to 2 blue, USP 10/0 and 9/0 black Made from: Excellent stitching characteristics and tight fit with few knots Recommendation of use: Cardio- and vascular surgery, skin occlusion Tensile strength: one, two, three or a dozen in environmentally friendly cardboard box Durability: USP: 10/0 bis 2 - metric: 0,2 bis 5 Length of thread: from 30 cm to 150 cm Nylon (Polyamide) is a monofilament, non-absorbable suture material made from polyamide. Because of its consistently smooth surface and litheness it glides very well. It distinguishes itself by high resistance to tearing and excellent stitching characteristics. Nylon - suture material is marked green.

Color: High tensile strength and good stitching characteristics, smoothness Recommendation of use: one, two, three or a dozen in environmentally friendly cardboard box Durability: USP: 12/0 bis 2 - metric: 0,01 bis 5 Length of thread: from 10 to 150 cm Polyester is a braided, coated, non absorbable suture material. The qualities and possibilities of use are very similar to those of polypropylene. Polyester offers a very good tissue compatibility and preserves its initial tensile strength for a long time. Polyester - suture material is marked orange Color: Very good tissue compatibility, very long preserving its initial tensile strength Recommendation of use: one, two, three or a dozen in environmentally friendly cardboard box Durability: USP: 6/0 bis 1 - metric: 0,7 bis 4 Length of thread: from 15 to 150 cm Silk is a natural, braided or swivelled, non absorbable suture material made from the cocoon of the silk spinner's caterpillar. A high resistance to tearing and a steady thread structure is guaranteed by a special braiding procedure.

Silk is easy in use, resistant to serum and water with a very safe knot fit at the same time. Silk suture material is marked light blue Color: What are Dissolvable Stitches Made of? Follow Us What are Dissolvable Stitches Made of? Stitches are always used by various doctors and surgeons to close deep cuts, gashes and surgical incisions. Today, they have started using dissolvable stitches/sutures especially for internal wounds. Let us learn about what these stitches are made of. Advertisement When a person suffers from an injury or undergoes any surgery, he/she is given stitches that help in holding the body tissues together. The surgical suture involves use of a needle and thread. The body part is sutured back together just like you would stitch clothes. However, the type, size, shape as well as material used for the thread is very different. There are two types of threads used by medical professionals today. These include the non-absorbable and dissolvable (absorbable) stitches. We shall concentrate more on the most commonly used i.e., dissolvable sutures in this article.

Dissolvable and Non-absorbable Stitches Non-absorbable suture threads are made of materials that are not absorbed by the body naturally. They have to be removed from the body a few weeks after the wound closes and heals. In case of dissolvable ones, they are absorbed by the body over time. They need not to be removed and are mostly used in case of internal wounds where it is not possible to remove them. Materials Used in the Making of Dissolvable Stitches Dissolvable or absorbable sutures are those that lose their strength and get absorbed within 60 days. They get dissolved due to proteolytic enzymes in the body tissues or due to a hyrolysis reaction occurring within the body. There are different types of materials used in making them. Catgut Suture It is made by twisting together the strands of purified collagen that have been taken from bovine intestines. It is absorbed by the body within about 90 days. It is used for suturing ophthalmic, orthopedic, gastrointestinal as well as obstetrics/gynecological injuries.

However, it is banned in Japan and European countries due to the fear that it may pass on the bovine spongiform encephalopathy infection (mad cow disease) to the patient. Thus, it is today being replaced by synthetic absorbable polymers. Polylactic acid Polylactic acid (PLA) is thermoplastic aliphatic polyester material used to make dissolvable stitches. About 50% of its strength is reduced within 3 weeks and takes about 3 months to be dissolved completely. Polyglycolic acid Polyglycolic acid (PGA) is also a thermoplastic polymer, made from glycolic acid. It is widely used to make these threads around the world. About 40% of its strength is dissolved in a week and takes about 3 to 4 months to be totally dissolved in the body. Polydioxanone Polydioxanone (PDO) is a biodegradable synthetic polymer that has many biomedical applications. This material is used in many orthopedic, plastic and cardiovascular surgeries. Dissoluble ones take about 10 days to 3 months to be totally absorbed within the body.

They are very helpful in case the patient is not able to return to a medical setup for the removal. It is also used for internal injuries where it is not possible to operate the patient again, just to remove the sutures. They are thus, used for deep wounds on the skin surface, like during a heart surgery or some transplantation surgery. In some cases, it may also be used to repair perineum tears in women after childbirth. They have high tensile strength that holds the tissues or skin together until it heals. However, they disintegrate with time and will leave no foreign matter remaining in the body. Some patients suffer from inflammation, as their body may reject these stitches instead of absorbing it. If you have any doubts regarding the same, speak to your healthcare provider for further details. Batul Nafisa Baxamusa Operating Room Equipment / Instruments / Technique Flashcards - Cram.com 31 Cards in this Set Front Back What do we typically use for the subcuticular stitch? What is the stitch's typical half life? Monocryl. This is a synthetic absorbable suture that is monofilament, which makes it less reactive to the tissue.

It comes in both dyed and non-dyed and it is usually used for closing the skin. It has a half life of 7-14days. When closing small robotic 8mm ports or a 5mm port site, what suture technique does Dan McRackan use that makes it look much more asthetically pleasing? He instead of attempting a subcuticular stitch, uses a simple horizontal mattress suture, that really looks much better. What is Vicryl and what is its typical half life? icryl (polyglactin 910) is an absorbable, synthetic, braided suture, manufactured by Ethicon Inc., a subsidiary of Johnson and Johnson. [1] It is indicated for soft tissue approximation and ligation. The suture holds its tensile strength for approximately three to four weeks in tissue, and is completely absorbed by hydrolysis within 70 days. Vicryl and other polyglycolic acid sutures may also be treated for more rapid breakdown in rapidly healing tissues such as mucous membrane, or impregnated with triclosan to provide antimicrobial protection of the suture line.

Although the name "Vicryl" is a trademark of Ethicon, the term "vicryl" has become something of a generalized trademark referring to any synthetic absorbable suture made primarily of polyglycolic acid. Other brands of polyglycolic acid suture include Surgicryl, Biovek, Visorb, Polysorb and Dexon, all of which are manufactured by different companies We use it for the ureteral - bowel anastamoses, use it for closing the bladder sometimes,like chromic for the inside stitch and vicryl for the outside stitch in a two layer closure. it is one of our go to stitches. The half life is about 3-4weeks When mobilizing the omentum off of the colon, what does Dr. Calvo state is your mantra? There are no big vessels here, the blood vessels all come from the stomach via the gastroepiploics. There is no embryological origin in common to the two structures. The technique that Dr. Calvo also states is that you should cheat towards the colon cause you want as much omentum as possible.

He also states that you should have one person holding up on the omentum and the other person putting traction on teh colon and you just go through layer by layer and this will prevent you from inadvertently going through the colonic mesentary posteriorly as it will dive down. Why is it important not to pull to hard on the omentum when working on the left lateral side? You pull to hard and Dr. Calvo states that you can rip the capsule of the spleen whether it's cause the omentum gets stuck to it or what, but he says if you do that you get all kinds of bleeding and you get to do a splenectomy! When doing our ileostomy do we go lateral to the rectus musculature or in it? We don't go lateral we do a rectus splitting position and the reason for that I think is to try and reduce the ocurrence of hernias. When we had finished sowing up our rectal injury repair on Mr. Leech how did we test it? Dr. Wallen suggested a way they used to do it with teh syringe we use in the OR and blowing air in the rectum, Dr.

Calvo used a rigid anoscope and blew air in it that way and this caused air bubbles to blow up into some water that we had poured into the pelvis and that showed us that we had a leak and we had to put in more sutures. Dr. Calvo made a comment about how much serosa and mucosa to get when doing a closure as well, what was that? He said get a lot of serosa and some mucosa, he said just a little mucosa is all that you need. Is there a way to change the spacing between the eyes on the Da Vinci system? Yes, which is valuable I think for me, should play with it next time I am on the console. according to the module it is on the underneath side of the viewer area and will change the spacing like with a pair of binoculars. When docking the robot and you have each arm docked you might look at it and think that the arms are going to clash, what is a way to test to see if that is true? One way to test is to just hit the clutch on the arm and see if they clash because the only movements that the arms will make when in an operation are those at that joint.

Should you use the clutch when docking the arms? No, you should avoid using the clutch if you can. Have to ask Dr. Pruthi and Dr. Wallen about how far apart the robotic ports should be, what is the difference between what we say and what the site says? 10cm versus 8cm. How do you decide how far away the camera port is for the surgery? The site says that you want it 10-20cm away from the surgical site in question, so the prostate for example then we make a line 20cm up and that is our camera port. What is the so called sweet spot for the Da Vinci system? 10cm spacing between the center column and the first arm of the camera port. What is a good estimate of 10cm distance apart that the Da Vinci arms should be from the camera port? About a hand's width. If someone wants to remove an endowrist instrument to change it out for something else and I am at the console, what should I do? You have to straighten out the instruemnt and open the jaws because otherwise the instrument shouldn't be easily removed as a saftey mechanism of the system.

When doing robotic prostatectomy what does Dr. Pruthi say about speed when tying down your knots? *He says not to get in a hurry, don't try to be fast. He would rather you go slow and be in the right planes for tying down your knot. How do you hold the needle when throwing the first throw on the DVC stitch? *You hold it on top of the needle with the convexity toward the pubic bone and the concavity towards the prostate. Dr. Pruthi kind of angles it down a little bit when loading it. How do you throw the DVC stitch? * You again hold it with the instrument hand on top with it angled down a little with the convexity towards the pubic bone. When you find the spot that you want to go in you then push as if you are going towards the contralateral knee. You then will use your left hand to push against the prostate when you find where your needle is coming out to give you some tension to push against. You can use your left hand initially as well to hold over on the prostate towards the left when going to place the DVC stitch.

*Once you get the throw through you will pull your suture all the way through until you have a small tail. then take your left hand and grab both tails to pull up and tight and throw your DVC stitch again. Once you have pushed it through on the right side you can let go of the tails with your left hand and use your left hand to do the same maneuver as in the first throw to find your needle. *You then pull up through and if you need to at that point you can pull your loop through a little bit as well to shorten your right sided tail to sow to. *So then you will pull up towards the pubic bone with both sides to sinch it down. What do you have to do when tightening down your first knot of the DVC stitch? * you have to pull straigth up, then pull down and out, then regrab closer to the knot and repeat that move to make sure that your knot is tight. When cutting through the endopelvic fascia with the robot what is the move that Dr. Pruthi likes to use? * He wants you to use the heat to buzz in and then migrate towards the feet or the apex of the prostate.

He doesn't want you to use heat towards the base of the prostate as that is where the nerves are going to be entering in. What is the move at the apex of the prostate when you are trying to better define your DVC? *When taking down the endopelvic fascia more anteriorly as well as releasing the puboprostatic ligaments the move is to buzz superficially and then when you feel like you have a hole there slide your instrument in and tease away laterally and either more apically or laterally and more towards the base. *The move not to make is to put your instrument in and spread or to dig to deep in a hole that you can't see then you will get into the DVC. What if after you have incised through the endopelvic fascia you are trying to tease the levator muscles off laterally and they won't seperate? *If you really feel like you need the area for throwing or getting out the DVC stitch then you can grab the bundle with the bipolar and bipolar it *Once you have bipolared it then you cut cold through it. What is the move when trying to clear the superficial DVC and middle of the prostate over the DVC?

*Basically the move is sweeping in and under with one of the jaws of your maryland and bipolaring it, if you can't get everything in your jaws then you can push over with your scissors and load your bipolar up. *If you really feel that you have a big vein in there or the superficial DVC then you should bipolar it twice once closer to the pubic bone and once closer to the prostate so as not to just cut it and allow it to retract up under the pubic bone and bleed. How do you hold the needle with the robot when preparing to throw the DVC stitch? When dropping the bladder and entering the retropubic space, how can you tell if you are too close to the bladder? *Dr. Pruthi was stating that when you start to see more bleeding and don't get into that layer of thing flimsy stuff then you are probably too close to the bladder. When entering the endopelvic fascia lateral to the prostate where do we tend to enter and why? *Towards the base but somewhere around the middle of the prostate. When you put good traction and counter traction on the prostate you really can see where the endopelvic fascia and the levators come together.

We buzz into the endopelvic fasica instead of just cold cutting into the layer. *Once in the layer we put one tine of the scissors in and cut towards the base and then towards the apex buzz superficially and then mobilize the space between curving towards the puboprostatics. What is chromic suture? Absorbable biological suture material. Chromic is an absorbable suture made by twisting together strands of purified collagen taken from bovine intestines. Due to undergoing a ribbon stage chromicisation (treatment with chromic acid salts), the chromic offers roughly twice the stitch-holding time of plain catgut. The natural chromic thread is precision ground in order to achieve a monofilament character and treated with a glycerol containing solution. Chromic is absorbed by enzymatic degradation. Note – catgut is no longer used in the UK for human surgery. Proteolytic enzymatic digestion complete in 70 days. Absorption by enzymatic digestion and starts losing tensile strength on implantation from 18–21 days of catgut chromic What type of suture would you use for an orchiopexy on a torsion patient?

A fine nonreactive nonabsorbable suture such as an ethibond or a prolene, like 4-0. How much bupivicaine can you give a patient? The toxic dose is at 2.5mg/kg. But an easy way to get really close is that bupivicaine starts with a B, and that is the second letter of the alphabet. What is a pringle maneuver? In 1908, Pringle first described a technique to minimize blood loss during hepatic surgery by clamping the vascular pedicle.[1] The inflow of blood to the liver is via the hepatic artery and portal vein. Surgeons must be able to isolate and control these sources of blood flow not only to control bleeding in traumatic injuries to the liver, but also in elective hepatic resections. Clamping of the hepatic pedicle, also known as the Pringle maneuver, allows surgeons to evaluate traumatic liver injury. It does so by allowing one to determine if the hemorrhage is from branches of the hepatic artery or portal vein. When a clamp is applied to the pedicle, hemorrhage ceases if from either of these sources.

If hemorrhage continues then the other likely sources of bleeding include the retrohepatic vena cava or hepatic veins. Cram has partnered with the National Tutoring Association Claim your access Ready To Get Started? Surgical suture - wikidoc Surgical suture Surgical suture on a needle holder. Packaging shown above. A wound before and after being closed by interrupted sutures (simple and mattress). Micrograph of a surgical suture with a Foreign-body giant cell reaction. H&E stain . WikiDoc Resources for Surgical suture Articles List of terms related to Surgical suture Overview A suture is a medical device that doctors , embalmers, and surgeons use to hold skin , internal organs , blood vessels and all other tissues of the human body together after they have been severed by injury, incision or surgery . They must be strong so that they do not break, non-toxic, hypoallergenic (to avoid adverse reactions in the body), and flexible (so they can be tied and knotted easily). In addition, they must lack the so called "wick effect", which means that sutures must not allow fluids to penetrate the body through them from outside, which could easily cause infections.

Absorbable and nonabsorbable sutures Sutures (also known as stitches) are divided into two kinds – those which are absorbable and will break down harmlessly in the body over time without intervention, and those which are non-absorbable and must be manually removed if they are not left indefinitely. The type of suture used varies on the operation, with the major criteria being the demands of the location and environment. Sutures to be placed internally would require re-opening if they were to be removed. Sutures which lie on the exterior of the body can be removed within minutes, and without re-opening the wound. As a result, absorbable sutures are often used internally; non-absorbable externally. Sutures to be placed in a stressful environment, for example the heart (constant pressure and movement) or the bladder (adverse chemical presence) may require specialized or stronger materials to perform their role; usually such sutures are either specially treated, or made of special materials, and are often non-absorbable to reduce the risk of premature degradation.

Absorbable sutures Absorbable sutures are made of materials which are broken down in tissue after a given period of time, which depending on the material can be from ten days to eight weeks. They are used therefore in many of the internal tissues of the body. In most cases, three weeks is sufficient for the wound to close firmly. The suture is not needed any more, and the fact that it disappears is an advantage, as there is no foreign material left inside the body and no need for the patient to have the sutures removed. Absorbable sutures were originally made of the intestines of sheep, the so called catgut . The manufacturing process was similar to that of natural musical strings for violins and guitar, and also of natural strings for tennis racquets. The inventor, a 10th century surgeon named al-Zahrawi reportedly discovered the dissolving nature of catgut when his lute's strings were eaten by a monkey. Today, gut sutures are made of specially prepared beef and sheep intestine, and may be untreated (plain gut), tanned with chromium salts to increase their persistence in the body (chromic gut), or heat-treated to give more rapid absorption (fast gut).

However, the majority of absorbable sutures are now made of synthetic polymer fibers, which may be braided or monofilament; these offer numerous advantages over gut sutures, notably ease of handling, low cost, low tissue reaction, consistent performance and guaranteed non-toxicity. In Europe and Japan, gut sutures have been banned due to concerns over bovine spongiform encephalopathy (mad-cow disease), although the herds from which gut is harvested are certified BSE-free. Each major suture manufacturer has its own proprietary formulations for its brands of synthetic absorbable sutures; various blends of polyglycolic acid (Biovek for example), polylactic acid or caprolactone are common. Occasionally, absorbable sutures can cause inflammation and be rejected by the body rather than absorbed. Non-absorbable sutures 8 nonabsorbable sutures in a person's left thumb. Nonabsorbable sutures are made of materials which are not metabolized by the body, and are used therefore either on skin wound closure, where the sutures can be removed after a few weeks, or in some inner tissues in which absorbable sutures are not adequate.

This is the case, for example, in the heart and in blood vessels, whose rhythmic movement requires a suture which stays longer than three weeks, to give the wound enough time to close. Other organs, like the bladder, contain fluids which make absorbable sutures disappear in only a few days, too early for the wound to heal. Inflammation caused by the foreign protein in some absorbable sutures can amplify scarring, so if other types of suture are less antigenic (ie, do not provoke as much of an immune response ) it would represent a way to reduce scarring. There are several materials used for nonabsorbable sutures. The most common is a natural fiber, silk , which undergoes a special manufacturing process to make it adequate for its use in surgery. Other nonabsorbable sutures are made of artificial fibers, like polypropylene , polyester or nylon ; these may or may not have coatings to enhance their performance characteristics. Finally, stainless steel wires are commonly used in orthopedic surgery and for sternal closure in cardiac surgery . Surgical needles for use with sutures Surgical needles which form 3/8th of a circle, in different sizes.

Surgical needles which are semicircular, in different sizes. Traumatic needles are needles with holes or eyes which are supplied to the hospital separate from their suture thread. The suture must be threaded on site, as is done when sewing at home. Atraumatic needles with sutures comprise an eyeless needle attached to a specific length of suture thread. The suture manufacturer swages the suture thread to the eyeless atraumatic needle at the factory. There are several advantages to having the needle pre-mounted on the suture. The doctor or the nurse or odp does not have to spend time threading the suture on the needle. More importantly, the suture end of a swaged needle is smaller than the needle body. In traumatic needles with eyes, the thread comes out of the needle's hole on both sides. When passing through the tissues, this type of suture rips the tissue to a certain extent, thus the name traumatic. Nearly all modern sutures feature swaged atraumatic needles.

There are several shapes of surgical needles, including: straight Needles may also be classified by their point geometry; examples include: taper (needle body is round and tapers smoothly to a point) cutting (needle body is triangular and has a sharpened cutting edge on the inside) reverse cutting (cutting edge on the outside) trocar point or tapercut (needle body is round and tapered, but ends in a small triangular cutting point) blunt points for sewing friable tissues side cutting or spatula points (flat on top and bottom with a cutting edge along the front to one side) for eye surgery Finally, atraumatic needles may be permanently swaged to the suture or may be designed to come off the suture with a sharp straight tug. These "pop-offs" are commonly used for interrupted sutures, where each suture is only passed once and then tied. Sizes of sutures Suture sizes are defined by the United States Pharmacopeia (U.S.P.). Sutures were originally manufactured ranging in size from #1 to #6, with #1 being the smallest. A #4 suture would be roughly the diameter of a tennis racquet string.

The manufacturing techniques, derived at the beginning from the production of musical strings, did not allow thinner diameters. As the procedures improved, #0 was added to the suture diameters, and later, thinner and thinner threads were manufactured, which were identified as #00 (#2-0 or #2/0) to #000000 (#6-0 or #6/0). Modern sutures range from #5 (heavy braided suture for orthopedics) to #11-0 (fine monofilament suture for ophthalmics). Atraumatic needles are manufactured in all shapes for most sizes. The actual diameter of thread for a given U.S.P. size differs depending on the suture material class. U.S.P. Subcuticular Removal of sutures While some sutures are intended to be permanent, and others in specialized cases may be kept in place for an extended period of many weeks, as a rule sutures are a short term device to allow healing of a trauma or wound. According to about.com's article on nursing: [1] "Different parts of the body heal at different intervals.

Common time to remove stitches will vary: facial wounds 3–5 days; scalp wound 7–10 days; limbs 10–14 days; joints 14 days; trunk of the body 7–10 days. "Not all stitches must be removed. If a small area remains unhealed, notify the health care practitioner. Then if ordered, remove sutures from the healed area only." Suture materials Advantages Very high knot-pull tensile strength, good knot security due to special excellent handling features Very high knot-pull tensile strength, good knot security due to special surface finish, improved smoothness due to the dry presentation of the thread, excellent handling features High initial tensile strength, guaranteed holding power through the critical wound healing period. Smooth passage through tissue, easy handling, excellent knotting ability, secure knot tying Tensile strength retention, guaranteed holding power Indications For all surgical procedures especially when tissues that regenerate faster are involved. General closure, ophthalmic, orthopedics, obstetrics/gynecology and gastro-intestinal tract surgery. For all surgical procedures, especially for tissues that regenerate faster.

Subcutaneous , intracutaneous closures, abdominal and thoracic surgeries PDS is particularly useful where the combination of an absorbable suture and extended wound support is desirable, pediatric cardiovascular surgery, ophthalmic surgery Contraindications Not recommended for incisions that require the sustaining of the tissues for a prolonged period of time. Not recommended for an incision that requires sustaining of the tissues for a prolonged period of time. This suture being absorbable should not be used where extended approximation of tissue is required. This type of suture being absorbable is not to be used where prolonged approximation of tissues under stress is required and/ or in conjunction with prosthetic devices Precautions Special precautions should be taken in patients with cancer, anemia and malnutrition conditions. They tend to absorb the sutures at a higher rate. Cardiovascular surgery , due to the continued heart contractions. It is absorbed much faster when used in the mouth and in the vagina , due to the presence of microorganisms . Avoid using where long term tissue approximation is needed. Absorption is faster in infected tissues It is absorbed much faster when used in the mouth and in the vagina, due to the presence of microorganism.

Cardiovascular surgery, due to the continued heart contractions. Special precautions should be taken in patients with cancer, anemia and malnutrition conditions. They tend to absorb this suture at a higher rate. Special precautions should be taken in elderly patients and patients with history of anemia and malnutrition conditions. As with any suture material, adequate knot security requires the accepted surgical technique of flat and square ties. The PDS suture knots must be properly placed to be secure. Conjunctival and vaginal mucosal sutures remaining in place for extended periods may be associated with localized irritation. Subcuticular sutures should be placed as deeply as possible in order to minimize the erythema and induration normally associated with absorption. U.S.P. Needle Pull Specifications Other facts Tissue adhesives In recent years, topical cyanoacrylate adhesives ("liquid stitches") have been used in combination with, or as an alternative to, sutures in wound closure. The adhesive remains liquid until exposed to water or water-containing substances/tissue, after which it cures (polymerizes) and forms a flexible film that bonds to the underlying surface.

The tissue adhesive has been shown to act as a barrier to microbial penetration as long as the adhesive film remains intact. Limitations of tissue adhesives include contraindications to use near the eyes and a mild learning curve on correct usage. Cyanoacrylate is the generic name for cyanoacrylate based fast-acting glues such as methyl-2-cyanoacrylate, ethyl-2-cyanoacrylate (commonly sold under trade names like Superglue and Krazy Glue), n-butyl-cyanoacrylate. Skin glues like Indermil and Histoacryl were the first medical grade tissue adhesives to be used, and these are composed of n-butyl cyanoacrylate. These worked well but had the disadvantage of having to be stored in the refrigerator, were exothermic so they stung the patient, and the bond was brittle. Nowadays, the longer chain polymer, 2-octyl cyanoacrylate is the preferred medical grade glue encountered under various trade names, e.g. SurgiSeal, FloraSeal, and Dermabond.

These have the advantage of being more flexible, stronger bond, and easier to use. Antimicrobial sutures Another recent development in wound closure involves the use of sutures coated with antimicrobial substances to reduce the chances of wound infection. While long-term studies are not yet available, preliminary results indicate that these sutures are effective at inhibiting bacterial growth in wounds. See also

Question: Which absorbable medical suture is made by twisting together strands of purified collagen taken from bovine intestines?
Answer: CATGUT